Transcript Social Work: The New Leg in the Conditions for Coverage

The Enhanced Role for
Social Work in the
Conditions for Coverage
Jim Hafner, MSW, LCSW, LSCSW
DaVita Healthcare Northland
What Social Workers Have Always Done
to Evaluate Psychosocial Needs
• Cognitive status/capacity to
understand
• Ability to meet own needs
• Ability to follow prescription
• Mental health history
• Substance abuse history
• Coping ability/resilience
• Expectations for future
• Education/employment
status, concerns, goals
• Home environment
• Legal issues (guardian,
advance directive status)
• Advocacy needs
• Financial capability &
resources
• Access to community
resources
• Eligibility for Federal, state,
or local resources
Current Social Work Role
in Interdisciplinary Assessment
• Psychosocial needs
• Family & support system
• Abilities, interests,
preferences, goals including
participation in care, modality
& setting, expectations for
care outcomes
• Transplant suitability
• Physical activity level
• Suitability for referral to voc
rehab & physical rehab
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Current health status
Dialysis prescription
Blood pressure, fluid mgmt
Labs
Immunizations, meds
Anemia
Renal bone disease
Nutritional status
Dialysis access
Traditional Social Work Role in Long
Term & Short Term Care Plans
• Long Term Care Plan
– Long-term dialysis
status/interest
– Long-term transplant
status/interest
– Functional status
– Rehab status/interest
– Advance directive status
• Short Term Care Plan
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Health problems
Problems with labs
BP/fluid problems
Dialysis problems
Adequacy problems
Access problems
Psychosocial/mental
health problems
Expanded Social Work Role
in Plan of Care
• Achieve & sustain
psychosocial status
– Counsel and educate
– Community referrals
– Administer KDQOL-36
to measure function
• Rehab status & goals
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Education
Vocational
Physical
Age appropriate activity
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Dialysis dose
Nutritional status
Mineral metabolism
Anemia
Vascular access
Modality
– Home dialysis
– Transplant
Continuous Quality Improvement
• Facility based
• Problem focused
• Outcome driven
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Access
Adequacy
Anemia
Mineral metabolism
Nutrition
Transplant
Vocational rehabilitation
• Adherence
– Knowledge
– Creative motivation
• Resources & advocacy
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Transportation
Patient assistance
Insurance options
Nutrition programs
Vocational rehabilitation
Legislative
Quality Assessment &
Performance Improvement
• Effective, data driven
• Facility based, not patient
specific
• Uses MAT to focus on
indicators
– Improved health outcomes
– Prevention/reduction of
medical errors
• Documentation of QAPI
activities
• IDT reviews nine areas in
priority order
• Systemic & proactive
• Tracks & trends
• Seeks & welcomes patient
feedback
Optimizing Team Functioning
• Issues
– Census
– Documentation
requirements
– Staff stress
– Patient concerns
– Staffing/attentiveness
– Budget/finances
• Plan
– Effective time
management
– Review of patient input
– Acuity based staffing
– Competency-based
assignments
– Ease of recording
It Takes A Team